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PROOF OF INSURANCE (2017 - 2017) CLOSED CDATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/15/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONI ACt NAME. HCC Specialty PHONE FAX 401 Edgewater Place, Suite 400 ADDRESS; .E1Na)u (A/c,,No): P tY PRODUCER Wakefield, MA 01880 WST91AER In, ;'....,, INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: New Hampshire Insurance Company 23841 Robert Castle INSURERB: United States Fire Insurance Company 21113 14608 Fonthill Ave. INSURERC: Hawthorne, CA 90250 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iNTR INSR WVDr POLICY NUMBER t'Ed M�owyYYY) MM/DD/YYY. ..... TYPE OF INSURANCE EXP LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X SEL013687556 09/20/2017 10/10/2017 DAMAGE"TORENTED 300,000 SSPREMI E E OCCUR .( a,opcorronGe) $ CLAIMS-MADE X MFD FXP(Any one person) $ 5,000 X Host Liquor PERSONAL BADV INJURY $ 1,000,000 B Medical Expense US964001 09/20/2017 10/10/2017 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,OOO PR.y. X POLICY p ,It;,,��E LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO .... BODILY INJURY(Per person) $ ALL OWNED AUTOS ""' SCHEDULED AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS ..,,, $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE .., $ RETENTION $ ..., $ ,,... WORKERS COMPENSATION 1�➢C r U- i rry AND EMPLOYERS'LIABILITY Y/N „TORY I,IMJTS _F" ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFF ICER/MEMBER EXCLUDED? �.mm (Mandatory in NH) $ If yes,describe under E L DISEASE EA EMPLOYEE DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The Certificate Holder is added as Additional Insured with respects to our Insured's operations only This insurance is primary and non-contributory as required by written contract This coverage is with respect to EI Segundo Centennial Celebration event to be held 10/07/2017-10/07/2017 at Library Park EI Segundo CA CERTIFICATE HOLDER CANCELLATION City of EI Segundo, its Officers, Officials, employees, agents, and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED volunteers IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. POLICY NUMBER: 13687556 COMMERCIAL GENERAL LIABILITY CG 20 11 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS O LESSORS OF' IS S This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE ..................... Designation Of Premises (Part Leased To You): City of EI Segundo, its officers, officials, employees, agents, and volunteers, 350 Main Street, EI Segundo, CA, 90245 Name Of Person(s)Or Organization(s) (Additional Insured): City of EI Segundo, its officers, officials, employees, agents, and volunteers, 350 Main Street, EI Segundo, CA, 90245 Additional Premium: Included Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to 2. If coverage provided to the additional insured include as an additional insured the person(s) or is required by a contract or agreement, the organization(s) shown in the Schedule, but only insurance afforded to such additional insured with respect to liability arising out of the will not be broader than that which you are ownership, maintenance or use of that part of the required by the contract or agreement to premises leased to you and shown in the provide for such additional insured. Schedule and subject to the following additional B. With respect to the insurance afforded to these exclusions: additional insureds, the following is added to This insurance does not apply to: Section III—Limits Of Insurance: 1. Any 'occurrence" which takes place after you If coverage provided to the additional insured is cease to be a tenant in that premises. required by a contract or agreement, the most we 2. Structural alterations, new construction or will pay on behalf of the additional insured is the demolition operations performed by or on amount of insurance: behalf of the person(s) or organization(s) 1. Required by the contract or agreement; or shown in the Schedule. 2. Available under the applicable Limits of However: Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted This endorsement shall not increase the by law; and applicable Limits of Insurance shown in the Declarations. CG 20 11 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 1 DRIven uc#q$E N02733, 30, 000C rx '101120,20 i""NoNs CASTLE FN ROSER'T PETER FK 14008 FONT"LL AVE, HAWTHICIANEI,CA 00248 000 017'101/1954 :0TA NONg 11:954 SEX vel dIANO Flu EYE$RILU Hqt 8"'Ow� WOV look) 4! i W26!1 16 CALIFORNIA INSURANCE CARD State FaRiver tm CA Mulual Automobile eldinsurance Company 93311 900 Old Road Bakersfi , INSURED CASTLF,ROBERT P&AMELIA MUTL VOL POLICY NUMBERP35 6594-F22-75E EFFECTIVE YR 1996 MAKE TOYOTA JUN 22 2017 TO DEC 22 2017 MODEL CELICA VIN JTSF002T4T0031393 AGENT TOM BRUNDIDGE 1401-A75 PHONE �311P -5040 NAIC 26178 ( �MAGEPA VIDEO,BY 7NE.POLICY MEETS THE MINIMUM LIABILrrY LIMITS ')OVr %322 11 c"OR0111898 RLAW60 H 141 U Ul SEE REVERSE SIDE FORM DIPLAMATION. CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (_) I have and will maintain a certificate of consent of self-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code§3700 for the performance of the work set forth the agreement with the City of EI Segundo. Policy No. (_)I have and will maintain workers'compensation insurance as required by Labor Code§3700 for the performance of the work for which the agreement with the City of EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# ()0 1 certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not employ any person in any manner so as to'become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or een twill automatically become void. Signature of Applicant Date 09/13/2017 Agreement for: x Dated: . ° ,f Reviewed by: ;. .,..